Cochrane reviews are generally well-respected meta-analyses that are designed to answer important clinical questions. A Cochrane study ended the battle between OralB and Sonicare for supremacy in the electric toothbrush market. Their analysis showed that the OralB brush (at the time) was a better plaque-remover.

Single Versus Multiple Visits for Endodontic Treatment of Permanent Teeth: A Cochrane Systematic Review¹
Lara Figini, DDS, Giovanni Lodi, DDS, PhD, Fabio Gorni, MD, Massimo Gagliani, MD

The Cochrane Collaboration promotes evidence-based healthcare decision making globally through systematic reviews of the effects of healthcare intervention. The purpose of this systematic review was to investigate whether the effectiveness and frequency of short-term and long-term complications are different when endodontic procedure is completed in one or multiple visits. Randomized and quasi-randomized controlled trials enrolling patients undergoing endodontic treatment were identified by searching biomedical databases and hand-searching relevant journals. The following outcomes were considered: tooth extraction as a result of endodontic problems and radiologic failure after 1 year, postoperative discomfort, swelling, analgesic use, or sinus track. Twelve studies were included in the review. No detectable difference was found in the effectiveness of root canal treatment in terms of radiologic success between single and multiple visits. Neither single-visit root canal treatment nor multiple-visit root canal treatment can prevent 100% of short-term and long-term complications. Patients undergoing a single visit might experience a slightly higher frequency of swelling and refer significantly more analgesic use.

Before you pee on yourself out of excitement that the above study might provide some validation that single-visit root canal treatment in infected teeth offers the same therapeutic outcome as multi-visit treatment, realize a couple of things:

1. Double-blind randomized studies are rare in endodontic research, as are studies with adequate statistical power². A meta-analysis can only be as significant as the weakest study it includes.
2. Proper evaluation of endodontic healing based on radiographic changes is not appropriate after only 1 year. Strindberg³ showed this a long time ago, and so did Orstavik⁴ more recently.

1. Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005296. [↩]
2. Trope M, Delano EO, Orstavik D. Endodontic treatment of teeth with apical periodontitis: single vs. multivisit treatment. J Endod. 1999 May;25(5):345-50. [↩]
3. Strindberg LZ (1956). The dependence of the results of pulp therapy on certain factors. An analytic study based on radiographic and clinical follow-up examinations. Acta Odontol Scand 14(Suppl 21):1–175. [↩]
4. Orstavik D. Time-course and risk analyses of the development and healing of chronic apical periodontitis in man. Int Endod J. 1996 May;29(3):150-5. [↩]

Everyone likes to show off their best work, but when can you remember being at a continuing education presentation and the presenter shows off work that they have produced that is less than ideal?

Here is a case that was fraught with issues from the beginning:

The patient will be on a recall schedule with me for the next year or two while I keep tabs on healing within the jaw bone. Hopefully the problem of chronic infection from this tooth is solved. Options are very limited now if the infection persists.

If you want others to be happy, practice compassion.
If you want to be happy, practice compassion.¹

A friend who owns a small cabling business once told me that no matter how concerned a business-owner is about the welfare of their clients, some decisions that the business-owner makes are more in the best interest of the business rather than the client.

This is an undeniable fact that I agree with. These business decisions all end up impacting the bottom line, or profit, of the business. They range from things like using cheap materials to save on expenses, to unnecessary value-added goods or services, to pure and outright negligence.

Examples from around me? I’ve posted about some of them before, but read through the following groups and see if you can figure out the “ethical” difference of the examples in each group. I haven’t made up any of the examples:

Two examples of how to reduce expenses from a material/supply perspective:

1. On a day tour of cenotes (underground caves) in Mexico we arrived and set up to repel into the largest one of the day. The ladder via which our rope and harness was attached to (about 150 feet above the water at the bottom of the cave) was craftily and skillfully, rung by rung, taped together with duct tape.
2. How about the dentist that I know who orders one colour of white material for fillings. Every one of his patients who gets a white filling gets the same color of white. Not only that, but the excess filling material that is dispensed and doesn’t get used on your tooth, gets used in the next patient’s new filling.

Two examples of how to improve income by value-added services:

1. You decide that you want to learn to waltz. You take a few lessons at a ballroom dance studio. You are then strongly encouraged by the studio owner to pick up a multitude of other dances and a schedule of lessons because these dances will allow you not only to dance to other types of music, but will also indirectly give you training in frame, lead and follow, and floorcraft for the waltz.
2. Your dog while illegally out for a walk with you off his leash, attacks a neighbour’s (who is a friend) dog who is on a leash. The scuffle seems to end uneventfully. The next day the neighbour shows up and says his dog’s eye is swollen shut. You take their dog to a neighbourhood vet who runs a run-down walk-in clinic but is the only one available at that time to see the emergency. Antibiotic eye drops are prescribed along with a return visit in a week. The return visit is “free”. Uh huh. Within the week, the swollen upper eyelid looks almost as good as new. There is a little scar where the injury was, but that will probably continue to improve over time. We take the dog back to the vet for his free recheck. Although the visit is free, the value-added service is another prescription and dispensation of antibiotics for the scar, “just in case.” Antibiotic use for “just in case” is generally frowned upon these days.

Two examples of negligence:

1. In the practice of endodontics, controversy exists between the need for two visits to treat infected teeth, versus one visit. There is research evidence supportive of both sides of the debate. You choose to ignore the evidence supportive of two-visit treatment, treat everything in a single appointment, and present only the research supportive of single-visit treatment as your justification. There is a higher profit margin when teeth are treated in a single visit.
2. You don’t like doing root canals, your patients have a difficult time during the procedure, your patients return again and again after the procedure complaining of persistent symptoms, yet you continue to do root canal therapy as you always have, with no effort to improve your skills or understanding of the process. But…when your wife or kid needs a root canal, they are referred to me, the specialist.

Without turning this post into an ethics course, I think that most of you will agree that the number 1’s are less of a problem along the do-good/do-bad scale than the number 2’s. This probably is because the number 2’s are more fraudulent — they represent actions and situations where either a collective standard of treatment or practice is not upheld, or an outright deception is represented. There is a feeling that you’ve been robbed.

As a professional in business, the imperative to work ethically is a daily challenge for me. I have made good and bad business decisions that have directly involved patients.

So how do I make a split-second decision when deciding on the “right” thing to do? After reading through all of this, you might be surprised to find that the answer is very simple. The answer is the way that I live life daily. It is the Ethic of Reciprocity, or the Golden Rule. But I go one step further. I don’t treat you as I would want to be treated, myself. I treat you as I would want my brother, my mother, or my wife to be treated.

1. Dalai Lama [↩]

I enter the consultation room.

Me: Hi, I’m Peri Apex.

Him: Hi.

We shake hands.

Me: Your dentist has asked me to evaluate three teeth on the bottom that have had root canal work. Apparently you need some major restorative work done on them and there’s a question of whether or not the root canal status is stable.

Him: Yes, but let me ask you a question first about teeth that are impossible to freeze. One of the teeth that I’ve had a root canal on is impossible to freeze. At least 4 dentists have tried, but none of them have been able to get it numb and they all start off by saying that they’ll be able to achieve what the previous dentist wasn’t able to. So I had to have general anesthesia to get the root canal.

Me: Yup, sometimes teeth are difficult to numb up because of things like anatomic considerations or nerve inflammation in the tooth.

Him: No, this tooth doesn’t numb up.

Me: Well lower molars can be especially difficult to get fully numb.

Him: No, it was an upper tooth.

Me: Oh.

Him: My lip and cheek and gums were all numb but not the tooth.

Me: Getting teeth that are that sore fully numb is a challenge sometimes.

His voice now starts raising a notch.

Him: No, the tooth was not numb at all.

Me: The tooth was probably a little numb, just not enough to work on.

Now he sits up straighter, voice raises another notch.

Him: No. No. The tooth was not numb one bit. The dentists have told me all about where the nerves run, how they are supposed to be frozen in specific places, but I have a medical condition that prevents that particular nerve from getting affected by anesthetic.

I started raising my voice now because this silly, pointless conversation is dragging out too long. It’s not even one of the areas I’m supposed to check out.

Me: Have you had trouble getting frozen anywhere else?

Him: No, the condition is just with that one nerve in the area there.

Me: Someone told you that you have this medical condition?

Him: No, I know I do.

Me: What’s it called?

Him: I don’t know what it’s called.

Me: So how do you know that you have a medical condition?

I now realize that we’re both really getting pissed at each other.

Him: Because I’m telling you this is what happens when anesthetic is used on the tooth!

Me: How can you say that you have a medical condition like this when you don’t even have a name for it?

He looks at me with this incredulous look now.

Him: What are you talking about? There are lots of medical conditions without names.

Me: Well anyway this conversation is pointless because I’m looking at different teeth today anyway. They shouldn’t have a problem numbing up better if they need work.

Him: No, you don’t get it, the tooth didn’t numb up at all!

Me: The only way you can tell me that the tooth was completely unaffected by the anesthetic was if they tried to drill into it without freezing, then froze you up and then drilled into it again.

Him: Well it was not numb at all.

Me: You know, we’ve got lots of theories about teeth that are resistant to anesthetic; things like pH imbalances, receptor up-regulation, central facilitation and neuroplastic changes that affect receptive fields, but not one medical condition that describes one tiny, single nerve bundle to a tooth that is completely resistant to anesthetic.

Nodding the “whatever” nod at me.

Him: Uh huh.

And so the entire waste of a consultation appointment went. My insight into his argumentative nature became more detailed during this exchange:

Him: What forms of sedation are available here?

Me: Laughing gas, with freezing of course; a pill with or without a little bit of laughing gas; IV sedation via a dental anesthesiologist.

Him: Is freezing included with the pill?

Me: Yes, it’s included with all the sedation modalities. Don’t worry about freezing it’s a given.

Him: But you said laughing gas and freezing, you didn’t say it with the others.

Me: Don’t worry, no matter how deeply you are sedated, you’re getting freezing.

Him: Because of my subconscious maybe feeling stuff still?

Me: Yeah.

Him: Is General Anesthesia an option, do you do freezing with that?

Me: Inhalalation anesthetic is not an option here, but you would get freezing with that too if it were.

So…please do me first and make it quick before he needs to come back for work in that upper area where the medical condition lies.

Written on the referral slip that arrived with this patient was a note from their dentist, “Please perform apical surgery.”

I suppose the dentist was concerned about the post being irretrievable. My concerns were the probable coronal leakage that was causing the apical lesion and the fact that apical resection of the root would put me up against the end of the post — leaving me in a difficult position for a retrofilling. Apical surgery will not hold up against coronal leakage in a predictable fashion.

Assuming that the dentist could do a crown with a decent coronal seal, why not take the post out and retreat the root canal work? Retreatment would offer a more predictable solution for the tooth.

Ah, but a deep screw post like this is quite daunting to remove. We worry about the risk of fracturing or perforating the root.

Here’s what your average neighborhood endodontist should be able to do for you:

Microscopes, ultrasonic instruments, and training allow us to deal with cases like this in a conservative, predictable fashion. Orthograde retreatment of cases like these are viable options and should be presented to patients. Jumping straight to the surgical option is a disservice to your patient.

Update (August 14th, 2008): Here’s the post-op film: